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Literature Review:Essential health benefits in east and southern Africa

Todd, G., Mamdani, M. and Loewenson, R. (2016) Literature Review:Essential health benefits in east and southern Africa. In: EQUINET DISCUSSION PAPER 107.

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An Essential Health Benefit (EHB) is a policy intervention designed to direct resources to priority areas of health service delivery to reduce disease burdens and ensure equity in health. Many east and southern Africa (ESA) countries have introduced or updated EHBs in the 2000s. Recognising this, the Regional Network for Equity in Health in East and Southern Africa (EQUINET), through Ifakara Health Institute (IHI) and Training and Research Support Centre (TARSC), is implementing research to understand the role of facilitators and the barriers to nationwide application of the EHB in resourcing, organising and in accountability on integrated health services. This literature review provides background evidence to inform the case study work and regional dialogue. It compiles evidence from published and public domain literature on EHBs in sixteen ESA countries, including information on the motivations for developing the EHBs; the methods used to develop, define and cost them; how they are being disseminated and communicated within countries; how they are being used in budgeting, resourcing and purchasing health services and in monitoring health system performance for accountability; and the facilitators and barriers to their development, uptake or use. The literature review indicated that EHBs are widespread across the region, with thirteen of the sixteen ESA countries having them, albeit with different names applied to them and at different stages of implementation. All thirteen countries have designed an EHB or are in the process of updating it, ten have included them explicitly in policies; nine have implemented them and five have evaluated them. The majority apply them in the public sector at national scale. The development of an EHB was motivated by efforts to clarify health entitlements, to identify prioritised health interventions with cost benefit to meet priority population health burdens and to align resources to implement these services universally to all. EHBs are largely initiated and designed by central ministries of health, with involvement of external funders in some countries, and limited consultation with other stakeholders or communities. Most applied analysis of health burdens and cost-benefit interventions to identify services for inclusion, and some included a focus on specific areas of policy commitment, such as maternal and child health, where there was also sector-wide funding from external partners. It was not always apparent that those developing the EHB had adequate, quality population health information and costing data for this. In general, the methods and assumptions used for both prioritisation of services or their costing do not appear to be comparable across the region. The EHBs in ESA countries generally apply to all social groups and cover services from community to primary care to hospital level. The different EHBs in ESA countries cover specific communicable and noncommunicable disease programmes, maternal and child health and public health interventions, although with less common inclusion of laboratory, paramedical and allied services. Primary health care was a focus in all. EHB costs were differentiated by level of care, type of service provided and whether in the public or private sector. The estimated cost for public sector provision of the EHB of approximately $14-$25* per capita at primary care level and $40-$74 per capita, including referral hospital services, compares well with the $60 per capita estimated by the World Health Organisation (WHO) in 2008 for health system costs, if this is adjusted for inflation. (* all dollar figures refer to US dollars) While the EHBs are largely tax funded from government budgets, in most countries in the region the amount allocated from ministries of finance is insufficient to cover the benefit. If the cost of the EHB is estimated at about $70 per capita, then only seven of the sixteen countries had a total health expenditure post-2010 that covers this, and far fewer if only government expenditure/capita is used. In part, therefore, the costing of the EHB provides an estimate for ministries of finance on what budget would be needed to deliver what is regarded as an ‘essential benefit’ and the size of the public sector funding gap. The funding gap means that in most ESA countries out-of-pocket spending (OOP) and external funding in sector-wide approach (SWAp) type arrangements have been used to support delivery of the EHB. Such OOP spending, however, is often being collected through fee charges that contradict policy and raise barriers to care for poorest groups. External funding makes countries dependent on unpredictable sources for core services. The demand to raise additional domestic revenue has led ESA countries to explore other earmarked taxes and mandatory national insurance. Some countries have focused on delivery of specific priorities within the overall benefit package in the EHB, intending to roll out others as resources increase. Others have proposed to use fee charges for non-EHB services to fund those in the EHB. The EHB can play a key role in active and strategic purchasing of health services, widening performance funding from a narrow range of disease-specific outputs to a wider service package. This would be important also in decentralisation approaches being applied. However, the literature provided limited evidence of this use of the EHB, including with local government, private, mission sectors, and other nonstate providers, to align their services to priority benefits and monitor performance. The role of the EHB in purchasing (contracting and performance and equity monitoring) strategies would appear to be an area that needs further review within the region. From the five countries where evaluations have been implemented on their EHBs, there was some evidence of an implementation gap. The evaluations suggest that improvements in health and healthcare may arise from the use of EHBs, but that this depends on lower income groups accessing the services covered and on benefit packages being funded, available and effectively provided at primary care level and in district hospitals, with additional measures to ensure uptake in lower income groups and to control cost escalation. Designing and implementing an EHB was enabled by having access to capacities, methods and adequate quality data for the design, by collaboration across state and non-state actors, by having personnel and resources to implement it and by having the information and expenditure tracking systems to primary level to monitor it. The evaluations pointed to barriers within all these areas. These facilitators and barriers can be located within a wider demand for strengthening the health system. The limitations of this review are noted in Section 2, some of which can only be addressed through countrylevel assessment. Following the production of this review, the EQUINET programme on this area will be working with country teams led by ministries of health in four ESA countries to carry out more detailed case studies to assess the motivations for and methods used in developing and costing EHBs; the manner in which EHBs have been disseminated and used; promising practice, learning and the key issues for follow up, including bringing back wider regional exchange. The issues raised in the discussion point to areas for inclusion in the protocols for the more detailed assessment within countries, particularly since some work on EHBs is in progress or not documented in published literature. The follow-up could thus give attention to: a. The method used to assess and prioritise the benefits in the EHB, paying attention to programme areas and health system elements; b. The method used for prioritising services and costing of the EHBs and its alignment to ministry of finance, external and other funders; c. The methods of and challenges in blending funds from different sources for the EHB, how funding shortfalls are addressed and how new funding sources proposed or under policy dialogue will be pooled to provide the EHB for all; d. The factors enabling/disabling implementation, from design to monitoring and review, noting inclusiveness of participation in the design; collaboration between state and non-state/private actors; quality of information and expenditure on tracking systems; e. The use of the EHB in purchasing strategies with providers and the factors affecting this; f. The measures for governance, management of and accountability for the EHB and for managing the role of other sectors in the delivery of the EHB; and g. The areas of impact and methods used/suggested for evaluation of the EHB for strategic review.

Item Type: Conference or Workshop Item (Paper)
Keywords: Essential health benefits, Health Service Delivery, Disease Burdens, Equity in Health, EQUINET
Subjects: Health Systems > Community Health
Divisions: Ifakara Health Institute > Policy Translation
Depositing User: Mr Joseph Madata
Date Deposited: 27 Jun 2016 05:35
Last Modified: 27 Jun 2016 05:35

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